Modular impaction grafting tamps

ABSTRACT

An apparatus includes a plurality of separable impaction grafting tamps coupled to form an integrated impaction grafting tamp. In an alternative embodiment, an apparatus includes a first impaction grafting tamp defining a first channel including a sleeve portion and further includes an elongated member including an elongated first portion and an elongated second portion together defining a second channel. The first portion of the elongated member is positioned in the sleeve portion of the first channel, and the first channel communicates with the second channel to form an integrated channel including a first opening and a second opening axially spaced apart from the first opening.

FIELD OF THE INVENTION

[0001] The present invention relates generally to the field oforthopaedics, and, more particularly, to impaction grafting tamps.

BACKGROUND¹

[0002] Arthroplasty is surgery to relieve pain and restore range ofmotion by realigning or reconstructing a joint. Typical arthroplasticoptions include joint resection, interpositional reconstruction, andtotal joint replacement. Joint resection involves removing a portion ofa bone from a joint to create a gap between the bone and thecorresponding socket, thereby improving the range of motion. Scar tissueeventually fills the gap. Pain may be relieved and motion restored, butthe joint is typically less stable. Interpositional reconstructionreshapes the joint and adds a prosthetic disk between the bones formingthe joint. The prosthesis can be made of plastic and metal or from bodytissue such as fascia and skin. If the joint does not respond to themore conservative treatments (which may include medication, weight loss,activity restriction, and/or use of walking aids such as a cane), jointreplacement is often considered appropriate. Joint replacement (i.e.,total joint arthroplasty) is the surgical replacement of a joint with aprosthesis. Many joint replacements are needed because arthritis hascaused the joint to stiffen and become painful to the point where normaldaily activities are no longer possible. Arthroplasty, especially jointreplacement, is becoming an increasingly prevalent treatment. Forexample, it has been reported that more than 170,000 hip replacementsand more than 200,000 knee replacements are performed in the UnitedStates each year.

[0003] A conventional hip prosthesis includes an artificial socket and afemoral stem. The artificial socket is typically made of metal coatedand polyethylene (a plastic) to reduce friction. The femoral stem has aball at one end and an elongated post or spike at the other. In arelatively simple hip replacement operation, the surgeon makes anincision in the area of the distal femur and then pulls the distal femuraway from the acetabulum (socket of the hip bone). Next, the surgeoninserts the artificial socket into the acetabulum. The surgeon cuts andshapes the distal femur, inserts the post of the femoral stem into themedullary canal of the distal femur, and fits the ball of the stem intothe artificial socket. The surgeon secures the artificial socket and thepost of the stem within the acetabulum and the medullary canal,respectively, with an acrylic polymer (a synthetic cement).Alternatively, the artificial socket and the post may be designed forfixation by natural bone in-growth.

[0004] However, not all hip replacements are so simple. Impactiongrafting is increasingly incorporated in cases that are complicated bysubstantial bone loss within the femur. Impaction grafting is atechnique in which the surgeon uses impaction grafting tamps to impactmorselized allograft (a replacement material typically made from bonechips, among other things) into the medullary canal of the femur. Theallograft creates a new canal for receiving the femoral stem.

[0005] Conventional impaction grafting approaches include progressivelyimpacting the subject bone cavity with allograft to ensure a highoverall finished graft integrity. But properly aligning and otherwisemanipulating the differently sized and shaped tamps needed forprogressive impaction grafting has been challenging.

SUMMARY OF THE INVENTION

[0006] The present invention provides an apparatus including a pluralityof separable impaction grafting tamps coupled to form an integratedimpaction grafting tamp.

[0007] In an alternative embodiment, the present invention provides anapparatus including a first impaction grafting tamp defining a firstchannel including a sleeve portion. The apparatus further includes anelongated member including an elongated first portion and an elongatedsecond portion together defining a second channel. The first portion ofthe elongated member is positioned in the sleeve portion of the firstchannel, and the first channel communicates with the second channel toform an integrated channel including a first opening and a secondopening axially spaced apart from the first opening.

[0008] In another alternative embodiment, the present invention providesan apparatus for impaction grafting a canal including a first portionand a second portion. The apparatus includes a first means for impactiongrafting the first portion of the canal, and further includes a secondmeans, removably coupled to the first means, for impaction grafting thesecond portion of the canal.

[0009] The above-noted features and advantages of the present invention,as well as additional features and advantages, will be readily apparentto those skilled in the art upon reference to the following detaileddescription and the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0010]FIG. 1 shows an anterior plan view of an exemplary apparatusaccording to the present invention;

[0011]FIG. 2 shows a medial plan view of the exemplary apparatus;

[0012]FIG. 3 shows a lateral plan view of the exemplary apparatus;

[0013]FIG. 4 shows an exploded cross-sectional view of the exemplaryapparatus (without the guide rod), along line 5-5 of FIG. 2;

[0014]FIG. 5 shows an assembled cross-sectional view of the exemplaryapparatus (without the guide rod), along line 5-5 of FIG. 2;

[0015]FIG. 6a, FIG. 6b, FIG. 6c, and FIG. 6d show anterior plan views ofthe guide rod, the connecting screw, a connecting handle, and anextension member, respectively; and

[0016]FIG. 7a, FIG. 7b, FIG. 7c, and FIG. 7d show cross-sectional viewsof the guide rod, connecting screw, connecting handle, and extensionmember, respectively, along lines 7 a-7 a, 7 b-7 b, 7 c-7 c, and 7 d-7 dof FIG. 6a, FIG. 6b, FIG. 6c, and FIG. 6d, respectively.

DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENT(S)

[0017] Although various views of the drawings may be identified hereinas “anterior plan,” “medial plan,” “lateral plan,” and the like, it isnoted that these view designations are merely for clarity of expositionand, accordingly, they do not indicate limitations of the presentinvention.

[0018]FIG. 1 shows an anterior plan view of an exemplary apparatus 200according to the present invention. The various components of exemplaryapparatus 200 described herein are made from stainless steel, plastic,or any other material suitable for use in surgical procedures, and theyare of suitable size and weight for manipulation by hand. Additionally,the components of exemplary apparatus 200 are reusable, and accordingly,are made suitable for sterilization in an autoclave. Referring to FIG.1, exemplary apparatus 200 includes an impaction grafting tamp 210. Tamp210 includes an outer, tamping surface 220 and further includes anotched post 230. Next to post 230, tamp 210 also includes an inwardlyextending generally cylindrical bore 234 (see FIG. 2, FIG. 4, and FIG.5). In general, surface 220 is tapered and otherwise suitably shaped fortamping allograft into a proximal portion of a distal femur.

[0019] Apparatus 200 further includes an impaction grafting tamp 240.Tamp 240 includes an outer, tamping surface 250 that is narrowly spacedapart from surface 220 by a small (approximately 0.010 inches wide) gap260. In general, surface 250 is tapered and otherwise suitably shapedfor tamping allograft into a distal portion of the distal femur. Gap 260is large enough to prevent the edges of surface 220 and surface 250 fromwearing on each other, yet gap 260 is small enough to prevent allograftfrom becoming trapped between the tamp 210 and tamp 240 duringoperation. It should be appreciated, then, that surface 220 and surface250 together form a generally tapered, practically continuous tampingsurface. In alternative embodiments, surface 220 and/or surface 250 mayinclude any suitable additional tapering or even overlapping at gap 260to otherwise inhibit entrapment of allograft between tamp 210 and tamp240. It is reiterated, however, that apparatus 200 is merely exemplary.In alternative embodiments tamp 210 and/or tamp 240 may be replaced byone or more other suitably sized and shaped impaction grafting tamps forimpaction grafting a distal femur or any other bone cavity.

[0020] Further, apparatus 200 includes a connecting screw 270 and acylindrical smooth guide rod 280. Rod 280 has a diameter or width 284.As discussed in further detail below, screw 270 holds tamp 210 togetherwith tamp 240, and rod 280 extends through screw 270 and tamp 240.

[0021]FIG. 2 shows a medial plan view of exemplary apparatus 200. Bore234 and additional portions of surface 220 and surface 250, among otherthings, are discernable in FIG. 2. Meanwhile, FIG. 3 shows a lateralplan view of exemplary apparatus 200. Yet additional portions of surface220 and surface 250, among other things, are discernable in FIG. 3.

[0022]FIG. 4 shows an exploded cross-sectional view of exemplaryapparatus 200 (without guide rod 280), along line 5-5 of FIG. 2. Asdiscernable in FIG. 4, tamp 210 defines an elongated channel 300.Channel 300 includes an end opening 310 and an elongated cylindricalsmooth end portion 320 extending inwardly from opening 310. Further,channel 300 includes an end opening 330 and an elongated smooth portion340 extending inwardly from opening 330. Transverse to the elongation ofchannel 300, portion 340 has a rectangular, elliptical, or any otherwisenoncircular cross-sectional shape. In alternative embodiments, portion340 may be cylindrical. Additionally, channel 300 includes a cylindricalsmooth intermediate portion 350 extending between portion 320 andportion 340. The diameter or width of portion 320 (transverse to theelongation of channel 300) is greater than the diameter or width(transverse to the elongation of channel 300) of portion 350; the widthof portion 340 (transverse to the elongation of channel 300) is greaterthan the diameter or width (transverse to the elongation of channel 300)of portion 320; and the width of portion 340 (transverse to theelongation of channel 300) is greater than the diameter or width(transverse to the elongation of channel 300) of portion 350. Channel300 also includes a generally planar surface 354 rimming portion 350 andextending radially to portion 340.

[0023] Tamp 240 includes an elongated portion 360 and an elongatedportion 370 that together define an elongated channel 380. Portion 360has a transverse cross-sectional shape (transverse to the elongation ofchannel 380) that is about the same as, but slightly smaller than, thatof portion 340 of channel 300. It should be appreciated, then, thatportion 300 forms a sleeve that receives portion 360. Thus, in theexemplary embodiment portion 360 slidably (but not rotationally) engagesthe inside of portion 340; whereas, in alternative embodiments in whichportion 340 and portion 360 are cylindrical, portion 360 slidably androtationally engages the inside of portion 340.

[0024] Channel 380 includes an end opening 390 and an elongated smoothcylindrical portion 400 extending inwardly from opening 390. Channel 380also includes a threaded cylindrical portion 410 and an end opening 420.Portion 410 extends between portion 400 and opening 420. The diameter orwidth of portion 410 (transverse to the elongation of channel 380) isslightly less than that of portion 350 of channel 300, while thediameter or width of portion 400 (transverse to the elongation ofchannel 380) is less than that of portion 410. Additionally, thediameter or width of portion 400 is slightly greater than diameter orwidth 284 of rod 280 such that rod 280 (see FIG. 1) slidably androtationally engages the inside of portion 400. Portion 360 alsoincludes a generally planar surface 424 rimming portion 410 and opening420.

[0025] Screw 270 includes a cylindrical head 430 having a diameter orwidth about the same as that of portion 320 of channel 300. Head 430 hasa textured outer surface or any other outer surface suitable forgripping and manipulating screw 270 by hand. Screw 270 further includesa threaded shaft 440 having a diameter or width slightly less than thatof portion 350 of channel 300. The diameter and threading of shaft 440corresponds to that of portion 410 of channel 380 such that shaft 440screws into portion 410 and, thus, screw 270 holds tamp 210 togetherwith tamp 240. Additionally, screw 270 defines a cylindrical channel 450having a diameter or width about the same as that of portion 400 ofchannel 380, such that rod 280 (see FIG. 1) also slidably androtationally engages the inside of channel 450.

[0026]FIG. 5 shows an assembled cross-sectional view of exemplaryapparatus 200 (without guide rod 280), along line 5-5 of FIG. 2. Whenfully assembled, portion 360 of tamp 240 is inserted into portion 340 ofchannel 300 (of tamp 210) such that surface 354 of tamp 210 meetssurface 424 of tamp 240 (see FIG. 4). Further, portion 350 of channel300 communicates with portion 410 of channel 380 (see also FIG. 4) suchthat channel 300 and channel 380 form an integrated channel thatreceives screw 270 at one end and includes opening 390 at another end.It should be appreciated that this integrated channel is defined byportion 320 of channel 300 (see FIG. 4), portion 350 of channel 300,portion 410 of channel 380, and portion 400 of channel 380.Additionally, it should be appreciated that channel 450 of screw 270also communicates with portion 400 of channel 380 to form an integratedchannel that is coaxial with the integrated channel defined by portion320, portion 350, portion 410, and portion 400. As discussed above (seeFIG. 1), tamping surface 220 remains narrowly spaced apart from tampingsurface 250 by gap 260, yet the two tamps together provide a practicallycontinuous tamping surface. Thus, it should be appreciated that whenassembled tamp 210 and tamp 240 together form an aligned, integratedoverall impaction grafting tamp.

[0027]FIG. 6a, FIG. 6b, FIG. 6c, and FIG. 6d show anterior plan views ofguide rod 280, connecting screw 270, a connecting handle 460, and anextension member 470, respectively. In alternative embodiments, handle460 replaces screw 270 (see, e.g., FIG. 1 and FIG. 4). Handle 460includes a cylindrical head 480 that has a diameter or width like thatof head 430 of screw 270. Further, like head 430, head 480 has atextured outer surface or any other outer surface suitable for grippingand manipulating handle 460 by hand. Handle 460 further includes acylindrical threaded shaft 490 configured in a like manner to that ofshaft 440 of screw 270. Also, handle 460 defines a cylindrical channel500 having a diameter or width like that of channel 450 of screw 270(see FIG. 7). However, the lengths of head 480 and channel 500 aresubstantially greater than the lengths of head 430 and channel 450,respectively. The longer head 480 of handle 460 provides an integrallever (or handle) for manipulating alternative embodiments of thepresent invention.

[0028] Yet other alternative embodiments include extension member 470rather than screw 270. Member 470 includes a cylindrical threaded shaft510 configured in a like manner to that of shaft 440 of screw 270. Also,member 470 defines a cylindrical channel 520 having a diameter or widthlike that of channel 450 of screw 270 (see FIG. 7). Further, member 470includes a cylindrical head 530 of about the same length as that of head480 of handle 460. However, head 530 is smooth, and has a diameter orwidth only about the same as that of shaft 510. Member 470 provides aneffective extension of tamp 240 through portion 350 of channel 300(without holding tamp 210 together with tamp 240).

[0029]FIG. 7a, FIG. 7b, FIG. 7c, and FIG. 7d show cross-sectional viewsof guide rod 280, connecting screw 270, connecting handle 460, andextension member 470, respectively, along lines 7 a-7 a, 7 b-7 b, 7 c-7c, and 7 d-7 d of FIG. 6a, FIG. 6b, FIG. 6c, and FIG. 6d, respectively.

[0030] In operation of exemplary apparatus 200 for impaction grafting adistal femur, a rasp handle or any other suitable well-known handle typedevice is attached to tamp 210 via post 230 and/or bore 234 in awell-known manner. Next, guide rod 280 (alone) is inserted into thefemoral medullary canal and suitably aligned with the longitude of thefemur. Allograft is then suitably introduced into a distal part of thecanal. Tamp 240 and tamp 210, while held together by screw 270 (orhandle 460 in alternative embodiments), are slid over rod 280 viaopening 390 (tamp 240) such that rod 280 extends through portion 400 ofchannel 380 (of tamp 240) and through channel 450 of screw 270 (orchannel 500 of handle 460 in alternative embodiments). It should beappreciated that the engagements of tamp 240 and screw 270 (or handle460 in alternative embodiments) with rod 280 facilitate alignment oftamp 240 and tamp 210 with the longitude of the femur. Then, tamp 240and tamp 210, still held together by screw 270 (or handle 460 inalternative embodiments), are used to suitably tamp the allograft. Therasp handle merely facilitates manipulations of the integrated tamp asdesired. After the user becomes satisfied with the resulting distalgraft mantle integrity, the integrated tamp formed by tamp 240 and tamp210 is once again inserted into the canal. Screw 270 (or handle 460 inalternative embodiments) and tamp 210 are then removed, but tamp 240 isleft positioned in the distal part of the canal.

[0031] Next, with tamp 240 remaining in place, allograft is suitablyintroduced into the proximal part of the canal. This allograft is thensuitably tamped in the proximal part of the canal by sliding portion 340of channel 300 (of tamp 210) over portion 360 of tamp 240 and,generally, by moving surface 354 (tamp 210) to and fro surface 424 (tamp240). It should be appreciated that the slidable engagement of tamp 210and tamp 240 facilitates proper re-alignment of tamp 210 with thelongitude of the femur. Here, the rasp handle merely facilitatesmanipulations of tamp 210 as desired. Additionally, it should beappreciated that in alternative embodiments portion 510 of extension rod470 may be screwed into portion 410 of channel 380 (of tamp 240) suchthat head 530 of rod 470 further facilitates proper re-alignment of tamp210.

[0032] Finally, screw 270 (or handle 460 in alternative embodiments) maybe installed or re-installed through opening 310 (of tamp 210), withshaft 440 of screw 270 (or shaft 490 of handle 460 in alternativeembodiments) screwed into portion 410 of channel 380 (of tamp 240). Itshould be appreciated that for embodiments employing member 470, member470 must be removed prior to the installation of screw 270 or handle460. Screw 270 (or handle 460 in alternative embodiments) again securestamp 210 to tamp 240. This allows the integrated impaction grafting tampto be further manipulated as desired for trial reductions (mockassemblies in which the exemplary generally stem shaped integrated tampmay be fitted into an acetabulum to test alignments and/or depths of thenew canal) and/or for any other suitable work. For trial reductions withthe exemplary embodiment, a suitable provisional assembly (mock or trialball) may be attached to tamp 210 via post 230 and bore 234 in a wellknown manner. After the impaction grafting tamping is completed, theintegrated impaction grafting tamp is removed from the canal.

[0033] The foregoing description of the invention is illustrative only,and is not intended to limit the scope of the invention to the preciseterms set forth. Further, although the invention has been described indetail with reference to certain illustrative embodiments, variationsand modifications exist within the scope and spirit of the invention asdescribed and defined in the following claims.

What is claimed is:
 1. An apparatus, comprising: a plurality ofseparable impaction grafting tamps coupled to form an integratedimpaction grafting tamp.
 2. The apparatus of claim 1, wherein theintegrated impaction grafting tamp forms a practically continuoustamping surface.
 3. The apparatus of claim 1, wherein the pluralityincludes a first impaction grafting tamp defining a sleeve, and theplurality further includes a second impaction grafting tamp including anelongated portion positioned in the sleeve.
 4. The apparatus of claim 3,wherein the integrated impaction grafting tamp forms a practicallycontinuous tamping surface.
 5. The apparatus of claim 1, wherein: theplurality includes a first impaction grafting tamp and a secondimpaction grafting tamp, the first impaction grafting tamp is configuredto maintain an alignment with the second impaction grafting tamp, andthe second impaction grafting tamp is configured to maintain thealignment with the first impaction grafting tamp.
 6. The apparatus ofclaim 5, wherein: the first impaction grafting tamp defines a firstchannel including a sleeve portion, the second impaction grafting tampincludes an elongated first portion and an elongated second portiontogether defining a second channel, the first portion of the secondimpaction grafting tamp is positioned in the sleeve portion of the firstchannel, and the first channel communicates with the second channel toform a first integrated channel including a first opening and a secondopening axially spaced apart from the first opening.
 7. The apparatus ofclaim 6, wherein: the first channel further includes an end portionextending from the first opening toward the sleeve portion, and furtherincludes an intermediate portion positioned between the end portion andthe sleeve portion, the first channel has a length, the end portion ofthe first channel has a first width transverse to the length of thefirst channel, the intermediate portion of the first channel has asecond width transverse to the length of the first channel, the sleeveportion of the first channel has a third width transverse to the lengthof the first channel, the first width is greater than the second width,the third width is greater than the second width, and the third width isgreater than the first width.
 8. The apparatus of claim 7, furthercomprising: an elongated member extending through the first opening ofthe first integrated channel and extending through the second opening ofthe first integrated channel.
 9. The apparatus of claim 8, wherein theintegrated impaction grafting tamp forms a practically continuoustamping surface.
 10. The apparatus of claim 7, further comprising: anelongated member secured within the first portion of the secondimpaction grafting tamp and slidably engaged with the intermediateportion of the first channel; wherein the elongated member aligns thefirst impaction grafting tamp with the second impaction grafting tampbut allows the first impaction grafting tamp to move substantiallyrelative to the second impaction grafting tamp.
 11. The apparatus ofclaim 10, wherein the integrated impaction grafting tamp forms apractically continuous tamping surface.
 12. The apparatus of claim 7,further comprising: an elongated member secured within the first portionof the second impaction grafting tamp and extending into the end portionof the first channel; wherein the elongated member holds the firstimpaction grafting tamp together with the second impaction graftingtamp.
 13. The apparatus of claim 12, wherein the integrated impactiongrafting tamp forms a practically continuous tamping surface.
 14. Theapparatus of claim 7, further comprising: a first elongated membersecured within the first portion of the second impaction grafting tampand slidably engaged with the intermediate portion of the first channel,the first elongated member defining a third channel; and a secondelongated member; wherein the second channel and the third channelcommunicate to form a second integrated channel including the secondopening of the first integrated channel, the first elongated memberaligns the first impaction grafting tamp with the second impactiongrafting tamp but allows the first impaction grafting tamp to movesubstantially relative to the second impaction grafting tamp, and thesecond elongated member extends through the second integrated channel.15. The apparatus of claim 14, wherein the integrated impaction graftingtamp forms a practically continuous tamping surface.
 16. The apparatusof claim 7, further comprising: a first elongated member secured withinthe first portion of the second impaction grafting tamp and extendinginto the end portion of the first channel, the first elongated memberdefining a third channel; and a second elongated member; wherein thesecond channel and the third channel communicate to form a secondintegrated channel including the second opening of the first integratedchannel, the first elongated member holds the first impaction graftingtamp together with the second impaction grafting tamp, and the secondelongated member extends through the second integrated channel.
 17. Theapparatus of claim 16, wherein the integrated impaction grafting tampforms a practically continuous tamping surface.
 18. An apparatus,comprising: a first impaction grafting tamp defining a first channelincluding a sleeve portion; and a first elongated member including anelongated first portion and an elongated second portion togetherdefining a second channel; wherein the first portion of the firstelongated member is positioned in the sleeve portion of the firstchannel, and the first channel communicates with the second channel toform a first integrated channel including a first opening and a secondopening axially spaced apart from the first opening.
 19. The apparatusof claim 18, wherein: the first channel further includes an end portionextending from the first opening toward the sleeve portion, and furtherincludes an intermediate portion positioned between the end portion andthe sleeve portion, the first channel has a length, the end portion ofthe first channel has a first width transverse to the length of thefirst channel, the intermediate portion of the first channel has asecond width transverse to the length of the first channel, the sleeveportion of the first channel has a third width transverse to the lengthof the first channel, the first width is greater than the second width,the third width is greater than the second width, and the third width isgreater than the first width.
 20. The apparatus of claim 19, furthercomprising: an elongated member extending through the first opening ofthe first integrated channel and extending through the second opening ofthe first integrated channel.
 21. The apparatus of claim 20, wherein theintegrated impaction grafting tamp forms a practically continuoustamping surface.
 22. The apparatus of claim 19, further comprising: anelongated member secured within the first portion of the secondimpaction grafting tamp and slidably engaged with the intermediateportion of the first channel; wherein the elongated member aligns thefirst impaction grafting tamp with the second impaction grafting tampbut allows the first impaction grafting tamp to move substantiallyrelative to the second impaction grafting tamp.
 23. The apparatus ofclaim 22, wherein the integrated impaction grafting tamp forms apractically continuous tamping surface.
 24. The apparatus of claim 19,further comprising: an elongated member secured within the first portionof the second impaction grafting tamp and extending into the end portionof the first channel; wherein the elongated member holds the firstimpaction grafting tamp together with the second impaction graftingtamp.
 25. The apparatus of claim 24, wherein the integrated impactiongrafting tamp forms a practically continuous tamping surface.
 26. Theapparatus of claim 19, further comprising: a second elongated membersecured within the first portion of the second impaction grafting tampand slidably engaged with the intermediate portion of the first channel,the second elongated member defining a third channel; and a thirdelongated member; wherein the second channel and the third channelcommunicate to form a second integrated channel including the secondopening of the first integrated channel, the second elongated memberaligns the first impaction grafting tamp with the second impactiongrafting tamp but allows the first impaction grafting tamp to movesubstantially relative to the second impaction grafting tamp, and thethird elongated member extends through the second integrated channel.27. The apparatus of claim 26, wherein the integrated impaction graftingtamp forms a practically continuous tamping surface.
 28. The apparatusof claim 19, further comprising: a second elongated member securedwithin the first portion of the second impaction grafting tamp andextending into the end portion of the first channel, the secondelongated member defining a third channel; and a third elongated member;wherein the second channel and the third channel communicate to form asecond integrated channel including the second opening of the firstintegrated channel, the second elongated member holds the firstimpaction grafting tamp together with the second impaction graftingtamp, and the third elongated member extends through the secondintegrated channel.
 29. The apparatus of claim 28, wherein theintegrated impaction grafting tamp forms a practically continuoustamping surface.
 30. An apparatus for impaction grafting a canalincluding a first portion and a second portion, the apparatuscomprising: a first means for impaction grafting the first portion ofthe canal; and a second means, removably coupled to the first means, forimpaction grafting the second portion of the canal.